Provider Demographics
NPI:1205265709
Name:SIMMONS, EDWARD CORNELIUS (LMT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CORNELIUS
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15756 FORRER STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227
Mailing Address - Country:US
Mailing Address - Phone:313-273-8510
Mailing Address - Fax:888-270-1773
Practice Address - Street 1:15756 FORRER STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227
Practice Address - Country:US
Practice Address - Phone:313-273-8510
Practice Address - Fax:888-270-1773
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2550286225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist